MEDICARE: DUBOIS REGIONAL MEDICAL GROUP, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	363A00000X	Physician Assistant
2	363L00000X	Nurse Practitioner
3	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	002564699	OTHER	PA	HIGHMARK ASSIGNMENT ACCOUNT

General Provider Information

NPI Number	:	1760786834
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUBOIS REGIONAL MEDICAL GROUP, PC

Provider Business Mailing Address
First Line	:	100 HOSPITAL AVE
Second Line	:
City	:	DU BOIS
State	:	PA
Zip	:	15801-1440
Country	:	US
Telephone Number	:	814-375-6560
Fax Number	:	814-372-2848

Provider Business Practice Location Address
First Line	:	135 MIDWAY DRIVE
Second Line	:	SUITE B
City	:	DU BOIS
State	:	PA
Zip	:	15801-3857
Country	:	US
Telephone Number	:	814-371-1771
Fax Number	:	814-371-4417

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN S SUTIKA
Credential	:	CPA
Telephone Number	:	814-375-3385

Provider Enumeration Date	:	01/05/2011
Last Update Date	:	03/23/2015

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